Why don't private ambulance companies carry Succinylcholine (a neuromuscular blocking agent)?

From the Guidelines

Private ambulance companies do not typically carry succinylcholine due to its potential to trigger malignant hyperthermia, a life-threatening condition, and the need for immediate availability of dantrolene, a specific antidote, which may not be practical in pre-hospital settings 1. The use of succinylcholine in emergency settings, such as pre-hospital care, is limited due to the risks associated with its administration, including malignant hyperthermia, which can be fatal if not promptly treated with dantrolene 1. Some key points to consider include:

• The potential for succinylcholine to trigger malignant hyperthermia, although rare, necessitates the immediate availability of dantrolene, which may not be feasible in private ambulance settings 1.
• The requirement for advanced airway management capabilities and specialized training to safely administer succinylcholine limits its use to critical care transport teams, hospital settings, or advanced life support units 1.
• The risks associated with succinylcholine, including hyperkalemia, malignant hyperthermia, and prolonged paralysis, make it a less desirable option for private ambulance companies that primarily provide basic or intermediate life support 1.
• The need for refrigeration and the relatively short shelf life of succinylcholine make it impractical for many private ambulance services 1. Overall, the potential risks and logistical challenges associated with carrying succinylcholine make it unlikely for private ambulance companies to stock this medication, prioritizing instead the safety and well-being of patients in emergency situations 1.

From the FDA Drug Label

WARNINGS Succinylcholine should be used only by those skilled in the management of artificial respiration and only when facilities are instantly available for tracheal intubation and for providing adequate ventilation of the patient, including the administration of oxygen under positive pressure and the elimination of carbon dioxide. The reason private ambulance companies may not carry Succinylcholine is that it requires skilled personnel and specialized equipment to manage its administration and potential complications, such as respiratory depression and cardiac arrhythmias. The risks associated with Succinylcholine, including anaphylaxis, malignant hyperthermia, and hyperkalemia, also necessitate immediate availability of emergency treatment. Private ambulance companies may not have the necessary training, equipment, or protocols in place to safely administer Succinylcholine 2.

From the Research

Reasons for Not Carrying Succinylcholine

• Private ambulance companies may not carry Succinylcholine due to its potential risks and side effects, such as hyperkalemia, vagal arrest, and malignant hyperthermia, as indicated in studies 3, 4, 5.
• The use of Succinylcholine requires careful consideration and caution, especially in certain patient populations, and its administration can lead to severe consequences, including death, as reported in a case study 4.
• Alternative neuromuscular blocking agents, such as rocuronium, are available and may be preferred due to their safer profile and acceptable intubating conditions, as discussed in studies 3, 5.

Considerations for Emergency Airway Management

• The use of Succinylcholine for emergency airway rescue in certain settings, such as class B ambulatory facilities, is a topic of debate, with some arguing that the benefits outweigh the risks, as presented in a position statement 6.
• However, the potential for Succinylcholine to trigger malignant hyperthermia, even in the absence of volatile anesthetics, highlights the importance of having dantrolene available, as emphasized in a systematic review and database analyses 7.

Availability of Dantrolene

• The availability of dantrolene is crucial in settings where Succinylcholine or volatile anesthetics may be used, as delayed treatment can increase the likelihood of complications and mortality, as reported in a study 7.
• The use of Succinylcholine without dantrolene availability may not be recommended, especially in settings where the risk of malignant hyperthermia is higher, as suggested by guidelines and expert opinions 7.